Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Spring Break

Whenever the hype for March Madness comes around, my thoughts go toward Spring Break for undergraduates. For many in the Northeastern United States, a nor’easter has dumped enough snow (continues to dump snow/ice) that the prospect of heading to a warmer climate most attractive. Even if one heads to the ski slopes, it’s important to take this time, if available, to get away from your academics to recharge and see new scenery.

Some students will use the time to catch up or write papers that may be due towards the end of the semester but don’t use the entire break to work on academic matters. Go to a movie (check out the Oscar nominees for Best Picture) or see a musical, hear a concert or attend a play. In short, do something outside of your normal routine that expands your mind. Even exploring a new cuisine or reading a fiction novel is a great way to break out of the academic world for even 24 hours.

Rest, relaxation and breaks are as important as hard work in the pursuit of excellence. One can argue that if one “breaks” every weekend, one does not need much of a vacation but if those weekend breaks are your routine, do something different over Spring Break. It’s the different activity that allows the mind to recharge and sets new neural networks for use as you need them. Humans were never “wired” for routine and do best with change.

Knowing that one needs a break in routine is a useful characteristic to hone at the undergraduate level. Pursuit of medicine is stressful, long and can be all-consuming which isn’t good for mental health. Taking a break, even those weekend breaks is as important as disciplined, dedicated study during the week. Planning and executing plans are great but not planning, especially during a break is good too.

As a physician/surgeon, I took pride in not taking vacations as I built up my practice and research. Fast forward to today and I recognize the value of doing something different, interacting with colleagues outside of medicine/science and enjoying nature, sporting events and travel. I need my vacations now more than ever but I needed them as I started my career too. There is no pride in having a stress level that is on the verge of causing mental/physical breakdown.

In medicine, we often place our patients ahead of our families and ourselves. I can recall countless times, my father left the dinner table for an emergency or left a family gathering to take care of a patient. I have left graduations, dinners, weddings and other events because I was called into the hospital. At this point, I realize the toll that “being too available” has taken on my relationships and mental health. Today, I head out of town for my Spring Break to catch up on my reading (novels), watch those Oscar nominees and lie in the West Coast sunshine because I will return a better physician and professor for doing so.

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8 March, 2018 Posted by | academics, stress reduction | Leave a comment

Summer Vacation?

As many people are heading for medical school (or finishing up a year in medical school), the summer is a time for readjustment. This readjustment process can simply be looking a things that worked, or did not work, in terms of your studies. The readjustment process for those heading for medical school will be starting to simplify your life in order to anticipate and meet any challenges ahead.

Adjustments mean that one has to anticipate and evaluate all matters that involve your studies and your daily life in order to give your full attention to any tasks that must be completed. For example, for those starting medical school, most will have to adjust your study skills to master large amounts of information. The good part of this mastery is that the information will be presented in a manner for quick mastery but one has to have the mental confidence to put doubts behind and efficiently take care of your needs. In short, you won’t have time to be wasted. You have to hone in on what you need, ask for help with organization and keep moving as you adjust to the pace. Have the confidence to know that if you have been accepted into medical school, you have all of the tools to stay there.

If your year that is ending has not been as successful as you would like, make the adjustments that you need for success. Summer is a great time to have a chat with your faculty adviser in order to change anything that might need to be changed for the upcoming year. Allow the experience of your faculty adviser to guide your objectively so that you can be more successful. Rather than spending precious mental energy on comparing yourself to your classmates, compare yourself to you and upgrade you to master what needs to be mastered.

The most valuable lessons that I have learned in surgery, all center around one unchanging fact. That fact is that medicine/surgery demands that I constantly self-evaluate my practice, my learning and my approach to my work and make adjustments that will enable me to perform at my highest level. My patients don’t care about my doubts but only care about my ability to solve their clinical problems. To this end, I do my self-evaluation and self-criticism outside my clinical practice and bring my best into my clinical practice. I seek critique from my partners, my chairman and in many cases, from my friends who know me well.

I have to be willing to listen with an objective ear, something that is difficult for all of us whether we are inside or outside of medicine. We all love to believe that we are the best that we can be but part of that “believing that we are the best” requires that we have the mental ability to accept subjective criticism. Let the summer be a time that one seeks out the subjective, listens to what is valuable and rejects (be objective on your part), those items that don’t apply. Try to keep emotion out of this process as much as possible.

My other summer activity often centers around keeping (or getting) myself into the best physical condition possible. In my recent quest to master the marathon distance (26.2 miles), I have tended to neglect my strength training in favor of aerobic conditioning. While this has enabled me to lose plenty of weight, I know that I need to be both strong and aerobically sound. This summer will mean that I will spend some time with the weights again. At my age and at any age, strength training is great for discipline which is great for the demands of life (and medicine).

Physical conditioning and sports participation help to counter the extreme hours demanded by study and medical practice. Participation in team sports have always helped me appreciate the value that every member of the team brings to a successful challenge. In this manner, medicine is no different from winning a rugby match (my favorite team sport). Medicine, though the physician is at the top of the team, involves appreciation of the contribution and knowledge of every team members role in the health of your patients. Use your sports knowledge to help your professional knowledge and role as your learning moves along. Medicine is never practiced in isolation.

Summer is definitely a time to rest as well as readjust. This rest can take the form of a much deserved and needed vacation or simply involving yourself in something that is different from your medical studies. For me, travel is my rest and relaxation. My travels overseas have allowed me to look at other cultures that are far different from my own. My favorite activity is to put on my running gear and just explore my surroundings and observe people who are observing me. Every step that I take is a chance for me to connect with nature, my body and those around me. I tend to be the type of runner who greets those running around me and keeps moving. This habit has been a metaphor for my life and practice.

If you have a chance to do a bit of summer research, take the opportunity to relearn evaluation of scientific evidence, question practice guidelines and build up your knowledge database. Research moves at a slower pace than regular academic work thus taking a fresh look at your scientific questioning can be a useful undertaking. If you are new to research, summer is a great time to become familiar with the tools that will serve you well for the rest of your practice.

Medicine and surgery are professions of experience. Those with more experience teach and impart their knowledge to those will less experience. For me, a person who attended medical school at a later age, I learned that experience isn’t related to age. I learned to listen with care to those whose experience was greater than my own. Even today, I seek out experiences at every level because I appreciate the input of those who look at what I do with fresh eyes (those with less experience) and those with more experience. Medicine demands that I keep moving, just like my distance running demands that I keep moving.

Yes, summer is approaching quickly and will be gone just as quickly but summer offers an opportunity to slow down and self-evaluate. If part of that self-evaluation process involves reinvention of ones self as needed, then summer will be a great vacation.

 

 

26 May, 2016 Posted by | academics, medical school, medical school preparation, stress reduction | | Leave a comment

One Week to Go to My First Marathon

What have I learned about myself? With every mile that I have run in my training runs, I have learned that I have a mental toughness that I found quite elusive a couple of weeks ago. Now, I have learned to face my mental “demons” with calm reserve, much the same as I approach a difficult case or patient.

I had found myself sinking, for lack of a better word, into a spiral of self-doubt and mental vulnerability. My mental shenanigans cost me a wonderful friend but I now move forward with every step and pick up the pace without fear. I can’t reason why I spiraled a bit over my academic work but I did and it’s done. From here on out, I deal from a position of strength rather than questioning myself and my motives.

This past week, I have had the pleasure of thinking long and hard about my medical and academic career. After many years of practice, I believe that self-examination is not an entirely bad exercise but I have also learned that I cannot ask anyone else to “walk in my shoes” or “understand” the things that can send me into self-doubt. My questions were not about my training or my ability but about how I handle adversity in matters that I didn’t fully understand.

Yes, I have plenty of regrets that I lost the friendship of a gifted colleague but I discovered new insight into myself and new support from unexpected colleagues and friends. I took the time today on my last long run, to think of each of my friends and thank them as I ran. I am very grateful for their friendship and I know that I will continue to move forward professionally and personally.

I thought about setting goals and achieving those goals. Certainly, there is no guarantee that I will finish my first (and only) marathon race next week but I feel calm and physically prepared. Mentally, I am in a state of surprise in that I have been able to train for this race and that I will have the toughness to make the needed adjustments to my pace and form that will allow me to complete the distance.

This training has make me something of a philosopher in terms of what I see and hear around me. I have taken great pleasure in simple things like a wonderful warm shower or that drink of water when I have pushed myself to the brink of dehydration. I have tended to avoid the “sports” drinks because I haven’t felt the need for sugar/salt loading. Plain water, not too hot or too cold, has been my best friend.

My training has increased my need for rest and sleep. For most of my career, I have had a love/hate relationship with the number of hours of sleep that I require. Most days, I cannot sleep more than 5 hours but with my increased running mileage, I have moved into the six to seven hour range. More sleep has allowed my body to rest and heal for the pounding that the increased mileage required.

With the end of the school year, I am looking forward to taking a week or so off and heading to California for some much-needed relaxation. I love being near the Pacific Ocean, smelling the salt in the air and just watching the fog cover the Golden Gate Bridge from the deck of where I stay in the Bay area. I have also completed my longest and best runs up and down the hills of San Francisco, a place of unrivaled beauty and wonder.

Finally, I know that I cannot be “all things to all people” and I just need to let things fall as they will. For a surgeon who is quite used to affecting something definitive in most cases, letting go is a new feeling for me. Most of the time, things just work themselves out and I am the instrument. This has been the best part of my marathon training; seeing how I am an instrument of my training and experience.

This training for a marathon has been something of a metaphor for life for me. I set this goal and I have made some progress toward it in some manner over the past year. Though I didn’t reach the distances that one typically associates with distance running, I am very grateful for every step as I have moved along. Yes, I know I am a very secure middle-distance runner but stretching the distance has been good experience for me. With the stretch has come great self-knowledge.

 

8 May, 2016 Posted by | medical school, medicine, practice of medicine, relaxation, stress reduction | , | Leave a comment

“It’s not a sprint, it’s a marathon.”

I am in the process of training for my first marathon. As a middle-distance runner at university, I always toyed with the idea of running 26.2 miles but after running a race of 10 miles about 20 years ago, I discovered that I didn’t enjoy running after the 8-mile mark. This put running the marathon distance on my “back-burner”, so to speak. There the marathon goal stayed until the idea surfaced about 4 months ago when I began running again for physical conditioning.

After graduate school, I attended medical school and found that I didn’t have much time for running as study was my constant companion.  If I had been wiser, I would have carved out time to keep up with my running, even 30 minutes three to five times per week, thus I would not have gained weight in medical school. My medical school weight followed me through surgery residency and fellowship. I kept promising that I would “get in shape” but never quite put a sound schedule together.

Well, after many years of practice and my sister’s wedding-photos of me were terrible, I decided to revisit getting in good physical condition. Since my weight slowly crept up to the heaviest that I had weighed in my life, I made the decision to lose a few stones so that my knees would hold up in my recreational rugby play. I kept up with my weight-lifting but my cardiovascular work was lacking in a major manner.

In the back of my mind, I knew that my knees would not want me to start out running, thus I began walking at least 30 minutes per session. I used my walking time to meditate (and pray) largely for stress relief. I had found that while lifting weights did relieve some of the stress, I missed running. I decided that I would attempt to get back to the point of being able to run a 10K if the opportunity presented.

Along with my dedicated walking, I changed my diet to no fried food, no candy, no processed food and certainly no “junk food”. My dietary habits were probably the easiest part of my journey because my wise sister had always been a great example for me. She simply doesn’t eat food that her precious body doesn’t deserve. She always said that it was better for her not that eat food that was processed. As I visit her often, I found that her consumption of fresh fruits and vegetables along with lean meats was a good strategy. She is lean, strong and wonderfully alive.

Soon, I found that by eating three nutritious meals with proper portion control, my weight was dropping. As I lost weight, I became faster finally able to jog and then run. Three weeks ago, when I was in beautiful San Francisco, I broke the 20-mile mark running those delightful hills as my training. It also helped that I have a wonderful colleague who was a world-class marathoner, until a devastating knee injury, but still maintains that wonderful thin body build of a marathoner. I envy his metabolism but he’s a great resource.

Today, I am many pounds lighter and running daily runs of 10 miles with great joy. My stress level is zero; my mind calm and at rest, my body continuing to thin out as my distances increase. While I am a bit worried that I won’t be able to finish the 26.2 miles, I keep running and keep running. I set the goal of completing a marathon and I work toward it daily by running, stretching and weight training also with keeping my diet sound. In short, I understand the concept of a “bucket-list” and I hope to mark “completed a marathon” off my bucket-list.

Another benefit of my running and weight loss is that people who haven’t seen me even as short as one month ago, barely recognize me. I have to say that losing enough weight to become unrecognizable is a wonderful benefit of this training. The only downside for me is that since I suffer from a hemolytic anemia (same as my father), I have to keep an eye on my blood counts. So far, even though I can chew red cells on my long slow distances (LSD), I remain asymptomatic. I can also indulge myself with an occasional beer or glass of wine without thinking about calorie counting. I have learned to savor those little treats of Sam Adams or Cakebread Chardonnay, my rewards for training hard.

Setting a long-term goal, working/training for that goal and getting that goal accomplished are items that are very nice for spiritual growth. Stress-reduction is great for intellectual and physical growth. In short, training for this marathon has been a great learning experience for me physically and intellectually. I can’t say  with certainty that I will finish those 26.2 miles but I can say that the journey so far, has been very positive. I am stronger and more resilient in all aspects of my life as my marathon training has spilled over into my academic and clinical practice making me calm, positive and accepting of things as they come, one step at a time. All in all, not bad and quite joyful at times. Bring on those 26.2 miles!

10 April, 2016 Posted by | life in medicine, medical school, practice of medicine, relaxation, stress reduction | , , | 2 Comments

New Year and new things!

We have changed into a new calendar year and some of you will be taking on new challenges in academics or medicine. The important thing to remember is that challenges are to be looked upon as a chance to change anything that needs to be changed but keeping a good course if your course has been fine. Change is inevitable in life and medicine thus embrace the change/challenge and keep your perspective.

Your perspective must include facing each challenge/change as it comes and doing your best. If you need help, don’t be afraid or so caught up in your ego, that you don’t reach out if you need to reach out. At the first sign of a problem, analyze situation and take care of it, seeking help when you need help. I am always amazed when residents or students tell me that they were afraid of what I might “think” if they sought help.

What I actually “think” is that if you need my assistance, ask and it will be provided. No one was born knowing everything in medicine. I certainly seek the assistance of my colleagues when I need them and never give a passing thought because the welfare of my patient is my only concern.

This tactic applies in academics too as you need to seek the help of your faculty even if you believe you are on the right track. Check your understanding to make sure that you are on course. If nothing else, you make get a better perspective and do even better. Faculty office hours are there for you to get help, get an understanding check and to keep you on course for your best performance. I can’t emphasize this fact with any more emphasis.

Your faculty are experts in their subject matter without exception. Take full advantage of that expertise and strive to get the best instruction possible. You are paying good money for that expertise so get everything that you can. It is far easier to be proactive concerning your studies than to do “damage control” because your ego was in the way of your judgment.

If you are starting clinical rotations, remember that your evaluations will be subjective. A good first impression can often make more of a difference in your clinical grade than anything else. You don’t have to “fake” an interest in everything clinical but you do have to learn to perform your best in a clinical situation. Be enthusiastic about the learning even if you don’t plan on entering a particular specialty. There is a baseline clinical knowledge that every clinician needs thus you need to be sure that you are well above that baseline.

I entered medical school with the idea that I would be a pediatrician, as I had an interest in adolescent medicine. I savored all of my tasks on my pediatric rotation (my first). Midway through clinical year, I found that I loved surgery more than anything I would ever do but that pediatric, family medicine and psychiatric knowledge (the rotations that I did before surgery) have been very useful in my career as a surgeon. In short, while you may change your mind as you are getting clinical experience, everything clinical is useful. Listen, learn, read, learn and ask questions as you go.

My last clinical rotation was Neurology/Neurosurgery. I learned to perform an accurate and thorough neurological exam. These skills have proven to be invaluable in the treatment of trauma and burned patients. In short, all clinical knowledge is useful for a physician or a physician assistant. In the middle of the night, that sound clinical base may make the difference in a patient’s outcome.

Again, mastery of the knowledge of a discipline is useful at the pre-med or pre-PA level too. Don’t approach a course as just something that you have to get an “A” in but look upon those courses as learning practice and useful for your future patients. I remember when I remembered that exogenous insulin did not contain Peptide C (cleaved out when endogenous insulin is synthesized by the body) thus checking a Peptide C level is a good idea in a patient who appears to have high insulin levels. If the Peptide C levels are low and the insulin levels are high, that insulin is coming from outside the body and not from something like an insulinoma (insulin-secreting tumor). I learned about Peptide C as an undergraduate student at university; reinforced in medical school.

Also remember that your faculty, undergraduate, graduate or medical school is there to see you successful. No faculty member gets “points” by having a high number of students fail to navigate their coursework. As a faculty member, my job is to help my students and residents to become the best professionals that they can become, without exception. I can’t “dumb down” the curriculum but I can give you every strategy that I know, to help you get the material mastered. My only hope is that you seek out help and get any assistance that you need.

My next point is for you to try to put yourself in the place of your patient. They are putting their health and trust in you to give them the best care that you can achieve for them. For me, this is the honor of being able to practice. The trust of a patient is something that I cannot violate under any circumstances. I might not have all of the answers but I have the stamina and the resources to get those answers. As I said above, I do not hesitate to consult a colleague when I need their expertise for my patient.

Finally, take time on a regular basis, to relieve the stress of being in an educational system. As a faculty member, I place a premium on my stress relief. For me, physical activity in the form of running, has been great for stress relief. I use that time for meditation/prayer, problem-solving and for the sheer enjoyment of pushing myself to the limit of my stamina. When I feel as if I am too tired to exercise, I go to the gym (or for a run) and I always feel better. If you can’t do 30 minutes, do 10 minutes but do something physical.

Trust the process because the process will get you where you want to go. Trust yourself and your feelings along with the process. If you find that your anxiety level is too high, do something to alleviate the stress. School or residency is not torture but a chance to see something new or learn something new. I can promise you that even a jaded old surgeon as myself, learns something new everyday!

 

 

5 January, 2016 Posted by | medical school, physican assistant, residency, stress reduction | , | Leave a comment

End of semester (academic year) thoughts

Introduction

We have made it through another academic year. We will welcome the Class of 2015 into the fold of graduates (from undergraduate programs, medical school and other graduate programs). I always try to reflect on what has been surprising for me during this past academic year and what goals I will set for myself (as a professor and as a physician) for the upcoming year. I am reminded of my own graduation from medical school with my hopes and fears of the unknown aspects of starting the next chapter in my career/life. Now, many years out, I am very happy that I see that I have challenges ahead, goals ahead and things to reflect upon.

My Surprises

As this year comes to a close, I am surprised that the gaps in delivery of health care to under-served populations is getting worse and not better. I have seen people come into my office with conditions that have been left for years that could have been taken care of in early stages but now are life-threatening. I read many medical journals each week to keep up with new advances yet seeing a patient with end stage renal failure because of untreated/improperly treated hypertension and diabetes is rampant. My colleagues who are on the front lines of treating under-served populations are frustrated with systems that still marginalize their patients, are frustrated with fighting for and not being able to see their patients get even basic medical care.

I am surprised that there is a disconnect between those who are responsible for running health care systems are so dedicated to making a profit that they are comfortable with denying services to people who desperately need them. This disconnect is getting greater. I don’t understand how those CEOs can look only at the “bottom-line” and not see the implications of their decisions. Running a health care system is not like running an oil company or a bank. If patients don’t have access to basic health care, they don’t have life.

I am surprised that many of my colleagues can look at patients and blame them for getting ill. Being sick is not a moral failing but a fact of life in terms of being alive. Yes, one does need to look at lifestyle changes that will enhance health but it’s not a personal or moral failing if patients are not able to make those changes. In this time of economic troubles, many patients simply do not have the financial resources, community resources to make the lifestyle changes that will enhance their health. We also have companies that again, look for providing the cheapest foods (usually fatty and sugary) while making healthier food choices far more expensive. Many of my patients eat from the fast food “dollar menu” not because they want to but because they have to. They are simply making choices that allow them to live indoors and are one pay check away from being homeless.

I am surprised that in this world of so many electronic/web informational resources, my students are less informed rather than being more informed. I say this with a bit of ambivalence because I don’t believe that my students’ lack of information is because that resources are not there but that my students are overloaded and their way of dealing with that overload is to turn-off rather than be selective and critical in their consumption of informational resources.

My Challenges

As a professor, I am charged with providing the critical thinking skills for my students to navigate the world of medical information. We, as physicians, have unprecedented access to the best evidence-based/science-based health care resources in the world. As a scientist/scholar, I am charged with questioning everything that I read regardless of how my information is delivered. Critical thinking and evaluation of the vast amounts of data about populations and individuals is a challenge that I must meet and teach to the next generation of physicians and health care providers. I must and I am constantly striving to evaluate and deliver the best evidence-based medicine based on data and research. I have to be confident that I am making sound decisions and I have to teach how to make sound decisions.

I am challenged to provide preventive strategies to my patients, where they live, that they can incorporate into their lives for the best outcomes. If I overwhelm my patients, they disconnect with preventive strategies and with health care in general. This means that I have to be able to explain what and why I am recommending a treatment strategy and I have to be able to recommend other treatment strategies and why I am not recommending those strategies no matter what they have seen on the telly or read online. I have to keep “one ear to the rail” in terms of what is circulating online and I have to keep the “other ear” to what is sound medical practice.

All of our challenges

Practicing medicine is more difficult today largely because of documentation issues. We are clicking away into our computers with poorly designed electronic medical records systems and filling out duplicate “paper work” late into the evenings after a long day in the clinic where we have been charged with seeing an impossible number of patients (again because our employers want us to turn a profit for them). Our challenge is to provide good delivery of health care but we have little support and assistance to do just that. At the end of the day, even if one has completed all of the documentation, there are few feelings of a “job well-done” and more feelings of “I failed on some many levels today.” Our biggest challenge is to remember that we are not the problem but we can be part of the solution by demanding that our talents and energies be focused on our patients and not on “paperwork”.

Our challenge is to look at anything and everything that we can change from within. We cannot allow a flawed system to push us further away from treating our patients because we can’t even “look them in the eye” because we are typing into a computer. We can’t keep skipping lunch, dinner and priceless interaction with our families and loved ones (our sanity) because we are so tied to trying to keep up. We can’t keep looking at the color, size and sex of a patient and dismissing them as individuals with unique needs. We can’t keep “writing off” whole populations of people because they are difficult to treat and because their culture is so different from ours. We can’t afford to say, “It’s someone else’s job and I will just refer them because they are too complex”.

We have to be challenged to take care of ourselves in terms of spiritual, physical and emotional health. No, self-care can’t be our only focus but we need to look inside of ourselves and figure out what is most important for our health and do things to keep ourselves both physically healthy and emotionally healthy. We can’t allow a very flawed health care system to result in our individual spiritual and physical to deteriorate to the point that we become a liability to ourselves and our patients. We have to learn to be selfish with our time and we have to have some outlets that will nourish us spiritually and emotionally. In short, we are crucial to our patients and we have to keep ourselves healthy and happy. Anything less is not going to work.

We have to learn to question everything. Do not just “take the word” of professors, websites, books, journals and other information resources as the only truth out there. Medicine is based on science and not on faith. You can have faith in your spiritual life (valuable) but you have to have the ability to cast a questioning eye on information in medicine. Look at alternatives and look at alternative solutions. Evaluate everything with a questioning eye. It is fine to question someone who is advocating a treatment and it is incumbent upon the advocate to explain their ideas. If you have questions, get them answered and constantly question others and yourself.

Finally, think about your experiences and learn from them. None of us was born knowing everything and our experiences are always learning opportunities. To evaluate yourself and your learning experiences is a very healthy way to learn to discard  that are not working and to embrace the things that are working well for us. Always looking for a way to do our daily tasks, job and learning in new ways is a great growth exercise. Again, my professors and my colleagues who constantly questioned me make me stronger rather than tearing me down. We all lamented about those “pimp sessions” but in the long run, they are opportunities for growth and reflection. As long as one is alive, there is opportunity for growth and learning; seize those opportunities.

 

30 April, 2015 Posted by | academics, medicine, stress reduction, success in medical school | 3 Comments

Achieving a balance

Introduction

As I write this, my career has been shifted into a higher level of comfort. I have spent the years since graduation from medical school and residency honing my surgical skills and the craft of taking care of patients. If anything has suffered in the task to become the best physician that I can possibly be, it has been my personal life. In short, it became easy to head off to the hospital or university rather than deal with things in my life that just were not working. Well, working in medicine has a way of making one reflect on what is truly important and making one move past things that are not a good fit for life.  I had decided after ending a relationship that had somewhat sustained me through medical school and residency, that I would throw myself into my work with vigor and a quest for self-discovery.

Make a definition of your “complete” life

I always knew that I was a person who saw the miraculous in all of medicine and humankind. I am just an instrument for our creator does the actual healing. You can call the creator anything that you like, God, Mohammed, the Great Spirit but positivity and balance have a way of forcing one to move along on a plane that is stable. One gets used to “death” as part of “life” and one can sometimes feel how to be aligned with the universe in one aspect of life but “going through the motions” in another aspect of life. So it was with me and I attempted to fill in my “gaps” and “blanks” with interests, flying, sailing and so forth. Being above the earth or on the ocean/lake can allow one to exhale and just marvel at how wonderful the world is at times. I also knew that I wanted to share the miracles of my life with another soul; as a human we all reach out for intimacy in some form. We can have a close friend or we can have a significant relationship (marriage) that allows us to find that person who can help us complete our mission in life. At times, I believed that I needed to work on myself and put all parts of my life in compartments so that I could achieve a close bond with another human that doesn’t mind that I sleep on my abdomen hugging a pillow and look like a “street urchin” in the morning after my nightly pillow fight; that my phone frequently rings all night if I am on home call; or that I might be away for 30 hours straight taking in house call. These are the realities of being in a relationship with most physicians and certainly with a surgeon. I can also add the time that I must spend in reading and study to keep up with my craft. In short, any person who is involved with a physician needs to see that they won’t have 100% of our attention all the time but when we are “with” you, we are 100% committed and need you like we need oxygen, food and water to live. My definition of my complete life was to meet and find a person who could be my friend first and perhaps more later. The inhumanity that is sometimes represented in my trauma bay can color how I look at relationships between humans. Domestic violence is very difficult to deal with but deal with it, I must and I must have a place in my mind that allows me to give my best treatment to the victims and sometimes to the perpetrator too. I am not the judge but only an instrument to an end point – getting that person back to health and solving health problems. My complete life has to allow me to find that person who can allow me to complete my “mission” on Earth and I complete them.

What I tell myself…

I had told myself that my life could be complete and satisfying with a job well-done. I would enjoy “discovering new truths” in my research and writings. I would enjoy hearing the successes of my students and colleagues. I would have a rich and satisfying career giving back with my skills and teaching. Yes, my life was indeed full but not complete. I didn’t have that intimate relationship that adds the depth and richness that just needs to be there. And so I was going through my career, happily enjoying my friends, colleagues and adventures in surgery, medicine, flying and sailing.

No, one can’t plan everything…

I was happily moving along with the things that occupy my time. I decided to do some exploration in trying to reach out and expand my circle of friends. It’s good to be a trailblazer in some aspects of one’s life. I have always challenged myself to take some risk with something at various times. I took a risk and was happily enjoying the experience when a man reached out to me in a most unexpected manner. There was something in the things that he shared so readily with me. He knew that I was a physician/surgeon yet he said that he saw something that drew him to me. At first, my scientific training kicked in and I attempted to define what was going on here; I ran in the opposite direction. Well, there is no definition but only that one has to have the courage and sometimes the faith to know that your instincts are correct (much the same as how I treat a critical patient). In short, life does not always come with clear directions. I have been in uncharted “exploration” the past few weeks and it’s been both exhilarating and unnerving at the same time.  Here I am in a relationship that I can’t plan or define and suddenly my life that I thought was so full, seems empty before I was able to get to this point.

Why this is so vitally important…

In order to give our best to our patients and colleagues, we have to give our best to ourselves. My best now includes a very brilliant environmental engineer (he can’t stand the sight of blood) who inspires me to reach higher and further in all aspects of life. Suddenly the things that gave me immense satisfaction go beyond that and give me immense joy at the same time. I smile and laugh with my patients, my students and my colleagues. In short, he has made me a better and more fulfilled person. The only downside has been that my favorite OR music has moved from my signature “thrash metal” to a bit more “smooth jazz”. For those who work with me, that’s a huge change but they secretly like the music change. I am not playing as much Pantera or Goatwhore in the background. As you move through your university work and your preparation for medical practice, one has to have the best of humanity brought out from within themselves. To be able to give my heart, a myocyte at a time to this environmental engineer who can’t even see my lectures without getting sick, has made me a better surgeon, physician and human being. One simply has to find balance in all things in life and not shut off any part of life to focus on other parts of life.

10 October, 2014 Posted by | organization, relaxation, stress reduction | , , | 5 Comments

The Power of the Positive Inner Voice

Every year, many of my students start a new semester with the aim of changing anything that will make them more successful with their upcoming coursework. If there is one thing that you can change in the very next instant that will make the greatest difference in your performance, it can be that “inner voice” that tells you, “you are not good enough” or “this is a hard subject that I can’t do well in” or “I am not going be able to get all of this work done”.

It seems to be much easier to have an inner voice that is negative rather than positive. Many people are quick to employ the negative rather than the positive because the negative seems to be more believable. Most people are taught that a positive inner voice is the same as “patting your back” for non-achievement but the truth is that a positive inner voice is more about self-confidence than false self-aggrandizement. It is the confidence that one has to master in order to keep moving in a positive direction with any long-term goal. One has to believe that you will reach your goal in a series of small steps toward it on a daily basis.

Since you have total control over your “inner voice”, you can change anything that is negative such as “you are not good enough” to the positive such as “you are as good as anyone else” or make the change from “this is a hard subject that I can’t do well in” to “this may be a challenge but I will have small victories every day and get help the moment I need it”. In short, you can decide in the very next second that you will not listen to the voice that tells you what you “can’t accomplish” and replace that voice with one that tells you “what you have accomplished” and how you will keep accomplishing to meet any challenges head on.

Yes, students will fail exams and quizzes but learning from those failures will help make failing the complete course more remote. If you have never failed at anything in your life, you haven’t actually been tested. People who are untested do not develop the skills to learn from their failures and put them behind so that they can keep moving forward. If you keep spending precious time telling yourself what you “can’t accomplish” because of one set back, then you are likely to fulfill that negative inner voice that seems to be so tempting.

You can control how you react to a grade on a test or quiz. You can look at what you missed and make a careful assessment of what you need to work on so that you don’t keep making the same errors and master the material in a different manner. If you are only focused on the numerical score and not on mastery, you are likely to have difficulty integrating concepts and keeping concepts in your long-term memory (your goal for professional practice).

As I have stated many times on this blog, there has never been a course of study developed by one human being that another human being cannot master. Mastery of your studies does not take any super-human mental feats or membership in high-IQ societies but does take diligent and disciplined study for efficiency. If you use large amounts of time worrying about the rigor or the amount of material that you must master, you lose a great amount of efficiency. In the long run, your learning time for tasks and concepts becomes longer rather than shorter.

For example, as a junior surgical resident, I had to master many surgical procedures. If I had made a list of all of the procedures and cases that needed to be mastered, I would have been overwhelmed at the first case. Instead, I took each case as it came and worked on the fine points after I had mastered the major points. In short, by “divide and conquer”, I was able to master my procedures. I didn’t have the luxury to “think” about non-mastery as I ticked off things as they came under my review.

In residency, there is no person or class that pushes one to undertake daily reading and study. As the hours grow longer, it becomes easy to get behind unless one is vigilant. I set a goal of a minimum of 30 minutes of journal reading and 30 minutes of textbook reading per night with 2 hours on each Saturday/Sunday. I told myself, that I could get my goal accomplished and would get my reading goal accomplished. Like brushing my teeth, I quickly embraced my reading “habit” which meant that I was never behind when review for our yearly in-training exams came around. On same days, I did more because the habit made the task easier and more efficient.

During my residency research years, my reading schedule time tripled during the weekdays and was cut in half on the weekends because my time schedules changed drastically. When I went back to clinical work, it was difficult to stop reading and study because the habit had become so ingrained. I was amazed at the exponential learning that my solid reading schedule had afforded me during those research years. My reading and study efficiency had increased exponentially during this time which was the same exponential reading and study efficiency increase that I had experienced when I started medical school. In short, anything that becomes a habit becomes more ingrained/grooved and more efficient.

One can work on increasing confidence and from that one step, increase efficiency in almost any area of life that needs improvement. This improvement is invariably the result of one good habit leading to improvement in other aspects of one’s life. Just as when one starts a daily work-out program (can start with as little as 10 minutes per day), as the habit grows and becomes honed, other aspects of one’s life such as eating healthy and sleeping better start to improve.

What works for physical fitness can also work for mental fitness too. It always follows that people who are generally physically fit will experience less stress and more efficiency in their mental tasks. There have been plenty of scientific studies that show overall improvement in mood and health with increased physical conditioning. If you add mental conditioning in the form of adherence to a daily positive mantra, you are likely to see improvement in all aspects of your life too.You can start with one small change and keep reinforcing that small positive change on a regular basis.  It only takes a change in the very next instant to embrace the positive and confidence that you can keep going which will keep you on the right track.

4 September, 2012 Posted by | academics, medical school coursework, medical school preparation, residency, stress reduction, study skills, success in medical school | 3 Comments

Strategies for non-traditional success

Being Non-traditional

A non-traditional applicant  generally hasn’t taken the “traditional” route to medical school application (graduation from 4-year university with application in junior year). There is no particular “higher status” that applying to medical school as a non-traditional applicant will confer. In short, you are in competition with every applicant that applies to the schools that you apply to. The same criteria also applies to your undergraduate experiences and preparation for medical school. In general, many non-traditional applicants are older but this is not always the case. Sometimes an applicant is non-traditional because they didn’t attend primary or secondary school in this country but completed university here, worked a couple of years and then applied to medical school in their early 20’s. Certainly, this type of applicant is not traditional in any sense of the word but they would not be an “older” applicant as many nontraditional applicants would be.

While there is no age “limit” in terms of admission into medical school, certainly an older applicant needs to be sure that they are physically able to get through four demanding years of coursework and residency which is minimally three years. In today’s world, many folks who are in their 40s and 50s are in excellent physical condition and would have no problems with medical school, residency and practice. In my own case, I was over 40 when I applied to medical school and had no problems with school or practice.  I was heavily involved in middle-distance running  and tended to meet several older classmates on the running track. In short, the older students (a couple of service academy grads, a former olympic gymnast)  in my medical school tended to be in excellent physical condition. While many folks in their 20s and 30s would look at those folks who are in the 40s and 50s as “taking up a seat”, in general, the older applicants to medical school have no illusions that they need to be in good physical condition while the 20-somethings are often not as physically fit. If you are older, you should make physical conditioning a priority without question.

Keeping in good physical condition (at least 30-60 minutes of meaningful aerobic activity) can spell success in your academics. Physical activity is excellent for stress release and relief along with allowing one to foster discipline in life. It is the consistent and disciplined students who tend to perform best in medicine and in practice. Being able to work long hours (almost any specialty will demand this) will be much easier and better if you are in good shape. I can tell you that in residency, tennis, soccer and basketball along with running stairs became my means of keeping my head clear and my back strong. I played varsity tennis in college and continue to enjoy this activity well into practice. Having a physical activity or sport that can give you a good workout along with some social connections can be excellent. Even golf is good as long as you walk the course (I know the cart is fun but walk the course).  Twenty minutes of brisk walk on a treadmill a couple of times per day (listen to the audio summaries of your coursework) can be good for your physical condition and good for your head.

Turning disadvantage into an advantage.

Remove the thought that because you are a non-traditional applicant, medical schools are “hunting” for you. Medical schools do not have to hunt for any type of applicant or accept every type of applicant for diversity. This means that as a nontraditional applicant, you have to be just as competitive as a traditional applicant. Many times, many non-traditional applicants have had less than a great undergraduate record but taking a undistinguished undergraduate record into a competitive range is a very positive asset for a nontraditional applicant. Most admissions committees will look at recent coursework that is excellent and take into consideration that many students apply with a poor freshman year and turn things around for the next three years. While you won’t be applying with an undergraduate GPA (uGPA) of 4.0 (and you don’t need a 4.0) you will need to be above 3.5 to be considered minimally competitive and in the  3.6-3.7 range to be considered very competitive in addition to a strong score (31 or above) on the Medical College Admissions Test.

With those types of “numbers” out there, am I saying that you don’t have a chance? No, that is not the case but I am saying that you need to be realistic about your application when you are posting a uGPA or 3.5 along with a 28 MCAT and expect to be the nontraditional student at most allopathic medical schools. While the osteopathic schools do replace grades and make a good shot for the nontraditional applicant, you still have to do some uGPA “damage-control” if you have several grades of D in Organic Chemistry and have Cs in every pre-med requisite course. For any medical school, osteopathic or allopathic, the numbers are going to be more important and are going to be more important than the subject of the major that you have selected. In short, your application has to show recent can consistent scholarship in some manner. You have to get your academics in the best order that you can and optimize every part of the application along with excellent academics.

Many nontraditional students make the mistake of trying to take too many classes while working full-time. If you need to work full-time, your coursework need to be part-time. You are not going to get any “points” for a less than optimal performance (any grade below B+) in your coursework because you are working and taking a full load. Most allopathic medical schools are going to screen by uGPA which means that you need to make sure you meet and exceed the screen. When screening, most schools are not going to try to look at whether or not you are employed full-time. In short, drop back your courses (even if it take longer) until you can do excellent work in your courses. While you can’t allow your family (or yourself) to live outdoors while you are trying to take courses, you can cut back on the number of course hours that you take. If you are dependent on financial aid, take only the minimum of courses that keep your financial aid flowing. If you do well with the minimum, then add more but don’t overload and drop in the middle of the semester when you burn out on work and too much of an academic load.

You also need to take into account the demands of your courses. Taking three lab courses in one semester and trying to work full-time is not a sound strategy. When students (traditional or nontraditional) try to overload on coursework and work at the same time, it’s not the employment that suffers, it’s the academics. Again, it the performance that counts and not particularly the courseload because you are trying to “prove” that you can take many hours like a medical student. Additionally, your pre-med prerequisite courses need to be outstanding with the acquisition of a solid knowledge base for a good performance on the MCAT. For General Chemistry and General Physics, you need to have a very strong math background and thus, make sure you have good college-level algebra/trigonometry skills before you take those classes. If you need a math upgrade (or refresher),then take General Biology and math before you take General Chemistry and General Physics.

If you have a family, certainly there are things that you are going to have to take part in that your more traditional students will not have to deal with. You can become an expert with time-management and make time for the things that mean the most for you or you can resent the fact that you just have more demands. Balancing a family (does not mean that you inform the professor that your child has a play and you won’t be getting your assignment done that night) with excellent academics can be a huge positive when it comes to application to medical school. In short, make a schedule that allows you to get your studies done and take time for the people who you love. If you have a son or daughter’s play or a ballgame that you want to see, make that your recreation for the week and do your work with your recreation reward in mind.  Even better, schedule some physical activity with your child or spouse that will allow you to both spend time and get some benefit from the experience. Never, never use your family or job as an “excuse” for not getting your assignments done on time or doing poorly in a class or on a test. If you set a regular and consistent study schedule (without academic overload), you are likely to be more efficient rather than less efficient.

On the job

If you are working full-time, your job demands your attention when you are on the job. You can certainly bring a note card or two that you can work on when you are on your meal break but don’t expect your co-workers to “take up the slack” because you have a final exam coming up or because you are in school to become a doctor. First, your coworkers start to resent you and your work performance which makes the job more stressful for you. If you are on the job, you need to put in as much mental and physical energy as if you were not in school.  Again, cut back on the coursework if your job is very demanding and don’t count on breaks at work to be your study time as most people can’t get their homework done on the job. Pitch in and be a good coworker/employee while you are getting yourself prepared for medicine. These characteristics will serve you very well when you are both in medical school and in residency.

Studying and getting academics strong

If you have poor academics from an earlier attempt at university work, take your time and get As on your retakes. Taking Organic Chemistry three or four times with Cs is not going to get you into medical school. The retakes will be on your record and don’t bode well for an acceptance.  Before your start to prepare yourself for medical school (uGPA “damage control” or not), sit down with a counselor and take a good and objective look at your study skills and academic knowledge base. Do you need to upgrade your reading skills? Do you need to upgrade your math skills? Do you need preparation in critical thinking skills? In short, you need to have good communication (reading, written and spoken English), good critical thinking (math and logic) and a good academic base to show that you can get through a challenging medical curriculum. You can acquire these skills at any time but you need to get them. Take some time and put yourself in a good position to get the most for your tuition dollar.

As I stated above, there is no “hurry” to get into medical school. If you acquire strong academics, you can enter professional (medical, dental, law)  at any age. Take your time and get what you need. Medicine is a very long-term goal. It’s a bit like having 100 pounds of excess weight to lose. You are not going to be able to get that much weight off in two weeks even if you drink only water for that period of time. You are not going to turn a poor academic record around in one semester but you can start right this second to sit down and work out how you are going to achieve the excellence that you need. With any long-term goal, you can “tick off” the daily strides that you make toward it. Write down everything on everyday that you have done to get toward your goal even if it’s “studied and mastered all of the synthetic reactions for alcohols” .  Also, don’t forget to reward yourself for keeping on a straight path to your goals with excellent performance. Also, don’t forget to “forgive yourself” if you weren’t perfect in everything that you attempted. Being an obnoxious perfectionist will lead to burnout rather than excellence which is the real “key” to nontraditional sucess.

9 December, 2010 Posted by | age, medical school, medical school admission, stress reduction, study skills | 8 Comments

Study Skills – Part III

In this short essay, I am going to tell you something that I didn’t do that I should have done. It’s called “Learning by Experience”. When I started graduate school, I vowed to get myself into good physical condition. I had a few extra pounds but nothing that was morbid obesity just about ten extra pounds. I had been a middle distance runner (10K) off and on with my best mile time being 6:25 and my best 10K time being 40 minutes but working in the chemistry lab and getting ready for graduate school had eroded most of my base-line mileage. I saw the pounds creeping on and I decided to “stem the tide” right then and there.

I joined a gym where loads of guys from the U.S. Navy JAG office worked out. Soon I was grunting and sweating with the boys. Those extra ten pounds quickly melted off and I would run 4 to 5 miles daily. My flexibility increased and my brain loved the extra perfusion of oxygen from those daily runs either outside on the bike paths or inside on a treadmill. My workout partners, all JAG guys, introduced me to weight training. Soon I was benching 125lbs and leg pressing 400lbs.

I loved swaggering into the gym in my baggy gym pants and muscle shirt. I would hop on the stationary bicycle for a 6-minute warm up. After a few stretches, I would start my circuit working legs first then arms and finishing up with abs. I wore a red scarf on my head and definitely sweat as much as the guys. When I reached 80lbs on the bench press, I earned a spotter. Nothing gave me more satisfaction then when the guys and I would take turns on the chin-up bar. (No other women came near the bar). My biceps and triceps bulged. I would put 400 lbs on the leg press and just work away with some nice hamstring stretches in between.

After my weight-lifting, I would take a soak in the Jacuzzi and then a dip in the pool. I am not much of a lap swimmer but swimming a few laps would bring my body temperature down and would keep my back stretched out nicely. My entire gym routine took about 2 hours from start to finish. I would get a protein shake in the juice bar and head back to my lab feeling powerful and refreshed.

The best thing about being in such great shape was that the discipline of working out carried over into all aspects of my life. I slept better at night with no stiffness in the morning. I easily ran flights of steps and could carry heavy loads with no problem. My clothes fit great. I had a solid study plan that had gotten me a 4.0 in my graduate studies. While I ran, I thought of new experiments and analyzed my data in my mind. Though my diet was not bad (I am not much of a junk food eater), when I was working out, it was excellent. I ate plenty of fresh vegetables, fruits and little meat.

With all of my energy, I was able to awaken in the morning, run a couple of miles with the Marines from the barracks down the street, and then bike 6 miles to school in the dawn. I would check my experiments and review my lectures for the day. I would then shower (I really sweat when I bike); change into my suit and lab coat, and then do my morning lectures. During lunch, I would hit the gym. After lunch, I would study and prepare more experiments or go to meetings. This was the routine of an assistant professor.

When I decided to attempt medical school, I knew that I needed to take the Medical College Admissions Test (MCAT). I had far more coursework between a double major in biology and chemistry with double minors in physics and math. My graduate work was in Biochemistry and Molecular Biology so those subjects were well covered. I knew that I needed to brush up on my verbal reasoning skills so I bought a review book and worked some problems daily. I also worked on my Physics too since it had been five years since I had taken General Physics. I was solid on the Quantum Mechanics but Classical Mechanics and Optics needed review.

My graduate comprehensive exams were also looming that summer too. We would be examined over the course of two days with eight hours of testing on both days. I studied for my comprehensives and studied for the MCAT at the same time. This turned out to be a great strategy. I simply made a review schedule topic by topic and checked off as I reviewed each concept. As a poor graduate student, I couldn’t afford a prep course so I purchased ($35) a huge review book called Flowers and Silver. It was money well spent.

After completing my comprehensives in June and getting my AMCAS application done, I knew I had one month to prepare for the August MCAT. I had stuck to my study schedule and my workout schedule. The funny thing was that none of my graduate school colleagues, except my best friend, knew that I was even interested in medical school. My best friend in graduate school was a neurosurgery resident who was working on his Ph.D. We had been study partners for the comprehensive exams.

On the morning of the MCAT, I hopped on my bicycle and rode the 6 miles to my testing center. It was great rolling off the hills at top speed and feeling the early morning wind in my face. My legs were strong and I imagined myself “smashing” that exam as I pumped up and down the street. I stopped into my favorite coffee shop for a morning cup of fresh “joe” and a high-five from the shop’s owner (a little Korean lady who always offered me encouragement).

I stood in line, dressed in my bike shorts and muscle shirt with my helmet and gloves. I stretched some but other than that, I was pretty relaxed. I could feel the tension all around me. As I got to the test room, I hoped for a seat next to the window because outside, there was a beautiful pink blossomed tree. I knew that I would be able to look up and out the window for a little mental break if the test was too much. My prayers were answered as I took my seat next to the window.

I moved through the Verbal Reasoning. My strategy was to do the passages that I found least interesting first and the things I loved last. I paced myself reading the questions first and marking the answers as I read through the passages. I paid close attention to punctuation, tone and critiqued in the margins of the test booklet. Soon this portion of the test was behind me. About ten minutes into the test, three young men, arose from their seats and left the test center. Was I missing something? The entire test went fine for me with my being able to figure out the “hook” behind each question. It was more like a game than anything else.

At the end of the test, I rode to my lab, checked my experiments and said a “thank-you” to God for giving me a nice day to ride and a clear head. From then on, I was stayed in great shape and kept working out clear up until the last day of medical school orientation. When classes started, I started studying and eating. My study group would feast on Nacho Cheese Doritos as we quizzed each other. By the end of first year, I had gained 30 pounds. My teaching over the summer and second year packed on another 20. By the end of medical school, I had gained 65+pounds and carried that weight around until my third year of residency.

After three years of standing and huffing up stairs, I vowed to get the weight off. I didn’t have two hours to work out daily but I made time for an hour workout even if I lost sleep. On my call days, I would walk the steps. Soon I had a good aerobic base but I am still working on getting my weight lifting back up to my level before. Even today, I work out at least four to five times weekly doing something. My gym opens at 5:00AM so I can get an hour in on the elliptical trainer if necessary.

In short, in medical school, I let my fitness level drop and endangered my health. I am fortunate to be able to get back to my previous level of fitness though the weight is not coming off as fast as I would like. I know that I won’t lose as much weight until I can get my running base back and I won’t pound my knees until I have lost another 20 pounds. That day is coming though.

In short, get a good fitness plan today, if you don’t already have one. It can be as simple as a 30-minute walk after dinner. Keep yourself in good physical condition and take an hour for yourself because you deserve that time. Physical exercise drops your stress level and makes everything in your life hum. I am having some “zone days” now that my physical condition is getting better and better. Having a good physical conditioning strategy is as important to your studies as your textbooks. Get moving.

27 May, 2007 Posted by | MCAT, MCAT preparation, stress reduction, study skills | 2 Comments